The Political Economy and Stigmatization of HIV/AIDS in Patients Attending A Clinic in Lagos, Nigeria

iMedPub Journals
2015
International Archives of Medicine
http://journals.imed.pub
Section: Global Health & Health Policy

ISSN: 1755-7682
Vol. 8 No. 26
doi: 10.3823/1625
The Political Economy and Stigmatization of HIV/AIDS

in Patients Attending a Clinic in Lagos, Nigeria
Original
Abstract
Titilola T. Obilade MBBS,

Ph.D.
Background: The aim of the study was to highlight the politi-
Contact information:
cal economy of HIV/AIDS in people living with HIV/AIDS (PLWHA)

through use of relevant literature and administration of self-administered questionnaires. The study was carried out in the south-western
region of Nigeria, using patients attending the HIV/AIDS clinic at the
Lagos University Teaching Hospital, Lagos Nigeria.
Titilola T. Obilade MBBS, MPH,

FMCPH, MWACP, MILD, Ph.D.
Method: The questionnaires were distributed in the HIV/AIDS clinic

and respondents were interviewed by the Principal Investigator and
medical students. Results were collated and analysed using EPI INFO
6 statistical software. Chi Square analysis was used to test for association between categorical variables at a P value of 0.05. Results
were presented in tables and charts. Further, the study determined
the socio-demographic pattern of the patients, the changes in marital status, employment status and residential status since diagnosis.
In addition, the study sought to determine areas of stigmatization
as well as the fraction of monthly income spent on HIV/AIDS care.
Senior Education Specialist

Learning Sciences and Technology
144J Smyth Hall.
Virginia Polytechnic Institute and State
University.
Blacksburg, Virginia, 24061- 0488.
obilade@vt.edu
Results: Literature showed that employers were not willing to employ a person with HIV/AIDS and that vulnerable employment was
the predominant form of employment in sub-Saharan Africa. This
was re-affirmed by the study. Thirteen (13%) respondents lost their
jobs after diagnosis and about 75 (75.0%) of respondents were in
vulnerable employment. Sixty-four (64%) of the respondents were
married before diagnosis and 53 (53.0%) still married after diagnosis,
five of the respondents spouses had died, three had been divorced,
and four had been separated from their spouses (P < 0.05). Sixty-one
(61.0%) of the respondents got their financial support from their family. Stigmatization increased with the number of people that knew
of their diagnosis (P < 0.05).
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2015
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Conclusion: Loss of job occurred in respondents when the employers knew of the diagnosis. The household income spent on HIV/AIDS
care ranged from one-third to half of the monthly income. It was
recommended that the government provide incentives for employers
to hire PLWHA. Efforts should be made to reduce stigmatization
through health education. Health education should target employers,
religious organizations and family members. Self-sustaining financing
schemes should be developed for PLWHA and their families.
Keywords
Political Economy; HIV/AIDS; PLWHA; stigma; health education; employment;
workplace; socio-demographic; Lagos, Nigeria; sub-Saharan Africa
Introduction
The aim of the study was to highlight the political economy of HIV/AIDS and the stigmatization
of patients attending the HIV/AIDS clinic in Lagos,
Nigeria.
Objectives
1.To determine the socio-demographic pattern
of people living with HIV/AIDS (PLWHA) attending an human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) clinic at the Lagos University
Teaching Hospital, Lagos, Nigeria.
2.To determine how much of the household income is spent on HIV/AIDS care.
3.To determine change or loss of job if any after
diagnosis.
4.To determine change in marital status if any
after diagnosis.
5.To highlight areas of stigmatization of PLWHA.
Sub-Saharan Africa has 13 percent of the worlds
population [1] but is home to 71 percent of all
PLWHA [2]. Nigeria is the seventh most populous
nation in the world [1]. It has the largest number of
HIV/ AIDS cases in West Africa [2] and the second
largest number of infected persons in sub-Saharan
Africa. South Africa has the highest number of

PLWHA in sub-Saharan Africa [2].
The National Antenatal Care HIV prevalence increased from 1.8% in 1991 to 5.8% in 2001 and
dropped to 4.1% in 2010 [3]. Although the national
prevalence rate reduced, there was a variation in the
trends across Nigerias geographic landscape across
the states. The HIV prevalence rate ranged from 1.4
percent in Ekiti State (South West geo-political zone)
to 12.7% in Benue State (North-Central geo-political zone) [3]. There were also socio-demographic differences. Women, youth and people with low level
of formal education were the most severely affected
[4]. The prevalence increased for those in the 15-19
years age group while the highest prevalence was
in the 35-39 years age group [4].
Literature Review
AIDS in Nigeria
Following the first reported case of AIDS in Nigeria, [5] a National Expert Advisory Committee on
AIDS was created in 1987. The following year, the
National AIDS and Sexually Transmitted Infections
Control program was established under the health
ministry and because a multi sectoral response

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was needed, the National Committee on AIDS was

established in 2001 which eventually became an
agency in 2007 [4]. The National Committee on
AIDS was able to coordinate multi sectoral response [4]. Antiretroviral programs were started in 25
sites from 18 states. By 2013, there were 820 sites
across all the states [4].
The Hematology Department of Lagos University
Teaching Hospital began to see PLWHA before antiretroviral drugs were available and in 2002, it became one of the sites for the antiretroviral program.
The National Committee on AIDS in partnership
with the United States, Presidents Emergency Plan
for AIDS Relief (PEPFAR) and other international organizations subsidized the antiretroviral drugs for
patients and later, it was entirely free [6].
The provision of free antiretroviral drugs is a commendable effort but measures to control the disease must include steps to reduce the socio economic
burden of PLWHA particularly in the workplace.
Political Economy, HIV/AIDS and the

Workplace
Studies have shown that when PLWHA maintain
their employment, they have better quality of mental and physical health [7]. In a separate study, a
cohort of 319 PLWHA followed up for six years
showed that those that did not have a stable employment were two and a half times more likely to
die or become hospitalized [8]. In a National Longitudinal Mortality Study estimating life expectancy
by employment status, income and education for
White men and women, the largest difference was
for employment status. Employed White males lived 12 years longer than unemployed White males
and employed White females lived nine years longer than unemployed White females [9].
In sub-Saharan Africa, the employment-to-population ratio between 2000 and 2012 ranged from
64 to 65.3 [10]. In addition, the vulnerable employment is 77.4 percent [10]. Vulnerable employment
can be self-employment or work by contributing
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family members. They do not have a secure income

and lack social security [10]. A street vendor selling
chewing gum is in a vulnerable employment. The
challenge in sub-Saharan Africa is not the lack of
people in the work force but an inadequate production of goods and services [11].
Unemployment in Nigeria
In 2011, the unemployment rate for Nigeria was
23.9% [12] but it has been suggested that the figures are much higher [13]. The Nigerian labour
force includes those between the ages of 15 and
64 years old apart from students, home keepers,
retired people, those who stay at home to work
and those not interested [13]. Apart from the labour force contributing to the mental and physical health of the workers, it helps in building
the economy of the country. An increase in the
working force leads to a rise in the production of
manufactured goods which amplifies the countrys
purchasing power, ultimately fueling the economic
growth [14].
A study of the unemployment trends in Nigeria
between 1985 and 2009 showed that although
the Nigerian economy grew between 1991 and
2006 and the population increased by 36.4%,
unemployment increased by 74.8% [14]. Further,
the oil industry contributed 30.5% to the Gross
Domestic Product while the agricultural industry
contributed 36.7% implying that agriculture is the
major source of employment [14]. Unemployment
in Nigeria contributes to a low Gross Domestic Product, increase in crime, decrease output of goods
and services, increase in corporate crime and political instability [14]. Other factors identified as
contributing to unemployment are high population
growth rate, increase in the labour force, recessions, rural-urban migration, mismatch between
job seekers skills and employers needs and the
demise of small scale industries due to economic
policies [13, 15].

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Loss of Jobs for PLWHA

A study of the practices of small and large business
owners across some African countries showed that
in order to reduce the cost that an employee with
HIV/AIDS might incur, prospective employees have
to undergo pre-employment screening to rule out
HIV/AIDS infection [16]. Further, small and medium
sized businesses have several operational challenges like shortage of electric power, political instability and sudden and unexpected increases in taxes.
Therefore, managing an employee with HIV/AIDS is
not a welcome addition because they do not have
the resources to maintain PLWHA [16].
In a study conducted in Ilorin, Nigeria, 300 PLWHA
were interviewed and 2.7% of them admitted that
they had been denied promotion at work, 7.7% had
been threatened with termination and 0.2% reported employers refusal to hire them [17]. A quarter
of the respondents had experienced discrimination
from religious leaders, family members and health
care workers [17].
Loss of a job is a risk factor for deterioration in
the health of PLWHA apart from the ripple effects
it would have on the immediate family members
and eventually on the countrys economy. This study
highlights the political economy and the stigmatization of HIV/AIDS in patients attending the Lagos
University Teaching Hospital, Lagos, Nigeria.
Materials and Methods

This study was conducted within the old capital of
Nigeria, Lagos State. Lagos State is one of the major
commercial nerve centers of Nigeria. The study was
carried out in one of the oldest teaching hospitals in
Nigeria; the Lagos University Teaching Hospital [18].
The Lagos University Teaching Hospital is a tertiary
level of care that trains medical doctors and other
health professionals.
Ethical Approval
Ethical Approval for this study was obtained from
the Lagos University Teaching Hospital Manage-
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ment and consent for the interview was obtained

from each respondent before the interview could
proceed.
Questionnaire
The questionnaire consisted of 22 close-ended
questions. The questions elicited socio-demographic
data and change if any in marital, occupational or
residential status after diagnosis. The first six questions were on socio-demographic data. Questions
7 to 22 were on stigmatization, change of marital,
occupational or residential status after diagnosis.
The questionnaires were distributed daily for
one week by medical students volunteering as interviewers and by the Principal Investigator. Prospective respondents who declined to answer the
questionnaire were not persuaded to answer the
questionnaire. Names of respondents were not
required. Respondents were allowed to withdraw
from participation at any time during the interview.
Analysis
A total of 100 respondents answered the questionnaire. Raw data were coded and input into the
computer and analyzed by EPI INFO 6 [19] statistical
software. Entry errors were removed and analysis
was only done on the responses. The results were
presented in tables and charts. Chi Square analysis
was used to test for association between categorical variables at a P value of 0.05.
Results
There were more females than males giving a male
to female ratio of 1: 1.17. The modal age range was
25-34 years 42 (42.4%) followed by 35-44 years 31
(31.3%). The youngest respondent was 16 years old
and the oldest was 75. Most of the respondents
91 (91.0%) were Christians. Majority 62 (62.0%)
had completed either secondary school or tertiary
school education. Thirteen (13.1%) reported loss of
their jobs after the diagnosis. Majority of the respondents were of the Igbo ethnic tribe 46 (46.0%)

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followed by the Yoruba tribe 33 (33.0%). Although

there are many people from the Hausa tribe living
close to the clinic, none of the respondents marked
Hausa in their responses. However, one respondent
was Hausa. She was a 50 year old housewife married in a polygamous setting. She did not have a
formal education and was not aware of her diagnosis. She could not speak English. Her children had
been bringing her to the clinic for up to a year. The
children said their father would divorce their mother
if he knew of her diagnosis and were waiting for
their father to show manifestations of the disease
before telling him of the diagnosis.
Table 1. S ocio-Demographic Distribution of Respondents.
Distribution of respondents by sex
Sex
Male
Female
Total
Frequency Percentage
46
46.0
54
54.0
100
100
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Sixty four of the respondents (64.0%) were married before the diagnosis but only 53 (53.0%) remained married after diagnosis (P < 0.05). Four of
the respondents (4.0%) had been separated after
the diagnosis and three (3.0%) had been divorced
since the diagnosis. One artisan got married two
months after the diagnosis and he said his wife
was aware of the diagnosis. Five people (5.0%) had
lost their spouses to the disease after the diagnosis. Nine of the respondents (9.0%) were students
in tertiary education and two had completed their
academic degrees and were newly employed. Thirteen (13.0%) of the respondents became unemployed after the diagnosis
Figure 1: D
istribution of marital status before and
after diagnosis.
Distribution of respondents by age
Age (in years)

16-24
25-34
35-44
45-54
55-64
65-75
Total
7
7.1
42
42.4
31
31.3
15
15.2
2
2.0
2
2.0
99
100
Distribution of respondents by religion
Religion
Christian
Islam
Other
Total
91
91.0
8
8.0
1
1.0
100
100
Figure 2: D
istribution of employment status before and after diagnosis.
Distribution of respondents by level of education
Level of Education
Primary School Uncompleted
Primary School Completed
Secondary School Uncompleted
Secondary School Completed
Tertiary Uncompleted
Tertiary Completed
Total
7
7.0
12
12.0
15
15.0
34
34.0
4
4.0
28
28.0
100
100.0
2015

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Figure 3: D
istribution of respondents who had to
change place of abode after diagnosis.
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Table 2. C
hanges in residential and employment status after diagnosis.
Respondents who changed their place of abode after diagnosis
Changed
Address
Yes
No
Total
Frequency
13
84
97
Percentage
Non Response = 3
13.4
86.6
100
Distribution of respondents who lost their jobs after diagnosis
Loss of Job
Yes
No
Not Applicable
Total
After diagnosis, a total of 24 (24.0%) respondents employment status changed including changes through job loss or through graduation (P <
0.05). Thirteen (13.4%) had to change their place
of abode. Some could not change their residential
location because they lived in their own homes.
Most of the respondents had been attending the
clinic for less than six months 66 (66.0%) and 64
(64.0%) of them were diagnosed less than a year
ago. Only 8 (8.1%) had informed their employers
of their diagnosis. Other occupations included selfemployed and artisans. Some were previously not
employed or they were self-employed. Employers
awareness of diagnosis was not applicable to respondents that were self-employed.
About half of the respondents 48 (49.5%) felt
they had not suffered any loss. Family and job were
identified as the greatest losses 20 (20.6%) after
other losses like marriage and inability to educate
children. One person wrote that sex was the greatest loss. The most stigmatized areas of their lives
were family, work and friends 71 (75.5%).
On the number of people that knew about their
diagnosis, 43 (44.3%) of the respondents reported
that more than two people were aware. Stigmatization increased with the number of people that
knew about the diagnosis and was statistically significant (P < 0.05).
Frequency
13
49
37
99
Percentage
13.1
49.5
37.4
100.0
Non Response = 1
Employers' awareness of the diagnosis
Employers
Awareness of
diagnosis
Yes
No
Not applicable
Total
Frequency
8
34
57
99
Percentage
Non Response = 1
8.1
34.3
57.6
100.0
Table 3. Length of time since diagnosis and since

attending clinic.
Distribution of respondents by length of time since diagnosis
Length of Time
Less than one year
Up to 2 years but > 1 year
Up to 3 years but > 2 years
More than 5 years
Total
64
64.0
15
15.0
14
14.0
1
1.0
3
3.0
3
3.0
100
100
Distribution of respondents by length of time attending clinic
Length of Time
Less than 6 months
More than 6 months
but < 1 year
Up to 1 year but > 6 months
Up to 2 years but > 1 year
More than 3 years
Total
66
66.0
9
9.0
10
7
6
2
100
10.0
7.0
6.0
2.0
100
2015

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Table 4. Highlights of areas of stigmatization.

Respondents perceived greatest loss since diagnosis
Greatest Loss
Since Diagnosis
Job
Friends
Family
Others
None
Total
Frequency
10
8
10
21
48
97
Percentage
Non Response = 3
10.3
8.2
10.3
21.6
49.5
99.9
One
Two
More than
Two
None
Total
Frequency
57
40
97
Percentage
Non
Response
=3
58.8
41.2
100
11
1
10
11.7
1.1
10.6
71
75.5
1
94
1.1
100
Table 6. R
espondents financial support and income
spent on HIV/AIDS care
Frequency
Percentage
Non Response = 6
Frequency
Percentage
17
24
17.5
24.7
43
44.3
13
97
13.4
99.9
Non Response = 3
Relationship between number of people that knew of diagnosis

and stigmatization
Number of
People that
knew of
diagnosis
Women are more

Stigmatized
More than half of the respondents 57 (58.8%)

felt that women were more stigmatized. Religious
organizations and groups of people living with HIV/
AIDS (PLWHA) were not identified as areas of most
financial support. Some 11 (11.3%) did not have
any financial support. More than half of the respondents 58 (67.5%) spent between one-third and half
of their monthly income on HIV/AIDS care. The most
financial support came from family 61 (62.9%).
Distribution of respondents by number of people that knew

about diagnosis
Number that
knew
One Person
Two Persons
More than
Two Persons
None
Total
Table 5. D
istribution of respondents by opinion that
women are more stigmatized .
Yes
No
Total
Distribution of respondents by area of most stigmatization
Most
Stigmatized
Area
Family
Work
Friends
All of the
Above
Others
Total
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Ever Suffered Stigmatization

Non Response = 3, P < 0.05
Yes (%)
No (%)
Total
1 (5.9)
6 (25)
16 (94)
18 (75)
17
24
17 (39.5)
26 (60.5)
43
1 (7.7)
25
12 (92.3)
72
13
97
Distribution of respondents by area of most financial support
Area of Most Financial

Support
None
Family
Hospital
Religious
organization
Groups of PLWHA
Others
Total
11
61
2
11.3
62.9
2.1
0
23
97
0
23.7
100
Non
Response = 3
Distribution of household income spent on HIV/AIDS care
Percentage of
Non Response
Household Income
=14
Half of Household
30
34.9
Income
A Third of Household
28
32.6
Income
Two-Thirds of
7
8.1
Household Income
More than Two-Thirds
21
24.4
of Household Income
Total
86
100

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Discussion
Studies have shown that women are more disporpotionately affected by HIV/AIDS [2, 6, 17, 20].
The gender distribution in this study was similar
to other findings in south-eastern, north-central
and south-western regions of Nigeria with more
females living with HIV/AIDS [6, 17 ,20]. A study conducted in the north-central part of Nigeria
had more females 194 (64.7%) than males 106
(35.3%) and an almost even distribution of religion
between Christians (47.7%) and Muslims (52.3%)
[17]. Respondents in this study were predominantly
Christians 91 (91.9%) because in the south-western
region where this study was conducted, Christianity is the predominant religion. In a separate study
from the south-eastern part of Nigeria, females
162 (67.5%) were twice the number of males 78
(32.5%) [20]. The trend of HIV/AIDS varies across
Nigerias geographic landscape [2, 3].
Religious organizations were not listed as areas
of most support in this study. A study from the
north-central region of Nigeria showed that religious organizations stigmatized PLWHA by not
allowing them to participate in some activities and
they were isolated by other members [17]. Stigmatizers felt that HIV/AIDS was a punishment from
God and that they must have lived a deviant life
style [17].
Stigmatization was one of the reasons why people
were afraid of telling others about their diagnosis.
Unfortunatley, stimatization drives infected persons
into hiding and the disease is able to spread. A case
in point was the 50- year old female that her children had been bringing to the clinic for about a year
and she was not even aware of the diagnosis. Her
children did not tell her because they were afraid
she would be evicted from the home. The children
admitted that they preferred to wait till their father
began to show manifestations of the disease before
telling him of their mothers diagnosis. The family
is polygamous and their mother did not have any
formal education.
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The change in marital status was due to both

death from the disease and from separation or divorce. The respondents change in marital status
was usually seen as a loss but there was a man, an
artisan who got married after the diagnosis. Also, a
person that was attending the clinic for treatment
declined to take part in the questionnaire survey
because he had come to the clinic with his girfriend
and there was no way he could answer the questionnaire without his girlfriend being aware of his
diagnosis. The girlfriend did not know that she had
escorted her boyfriend to the HIV/AIDS clinic. While
the boyfriend was getting treatment, the girlfriend
was unaware of her boyfriends diagnosis and could
not get treated or tested.
Employers that terminated respondents with HIV
were ususally owners of small buisnesses although
one banker reported loss of his job after the diagnosis. Over seventy percent of employment in the
sub-Sahara is considered vulnerable employment
[10] and do not have a social security net and cannot take on what most employers would consider
a liability.
Buisnesses also mandate pre-employment screening to rule out PLWHA to keep costs down [16]. In
this study, most of the income earned was spent on
HIV/AIDS care and the support was mostly from family. Although the drugs are provided free, PLWHA
still have indirect costs related to their care. About
a third of the respondents 30 (34.9%) spent about
half of their household income on HIV/AIDS care.
Patients sometimes go to clinics far from their homes where they are not known and for some, the
transportation costs, travelling time, time away
from work and long waiting times are the indirect
costs [20].
With the prevailing economic situation, most
buisnesses are struggling to meet over head costs
and are not able to take on the burden of an employee with PLWHA [16]. In addition, vulnerable
employment is predominant in Nigeria. The care of
HIV/AIDS consumes a lot of resources and some

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respondents were no longer able to send their children to school. Education is a key to stepping out
of poverty especially where there is high unemployment and children of PLWHA whose education gets
trucated face challenges including risky life style behaviors and could be on a path to poverty. However,
PLWHA in the seventh most populous nation in the
world face difficult circumstances where unemployment is extremely high and stigmatization of the
disease is also high. Support by providing antiretroviral drugs is good but more should be done in the
area of employment. People with HIV/AIDS that are
able to keep their employment have better mental
and physical health,[ 7] live longer and have fewer
hospitalizations [8].
Recommendations
1.Health Education should focus on employers
of small and large buisnesses.
2.Health Education should also be extended to
religious organizations.
3.Efforts should be made to reduce stigmatization of HIV/AIDS through health education.
4.
Governments and Organizations should develop coping strategies for families with HIV/
AIDS.
5.
Governments should collaborate with International Organizations and develop income
self-generating ventures for PLWHA and their
families.
6.Governments should develop a scheme that
gives incentives to employers that employ
PLWHA.
7.People with HIV/AIDS should be counseled to
tell their HIV/AIDS status to their sexual patners.
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None of the respondents identified as Hausa even

though there is a predominantly Hausa community
close to the hospital. There had been a change in
marital status after diagnosis. The change was usually a loss of patner by separation, divorce or death
but one respondent got married. There was loss
of job after diagnosis usually if the employer knew
of the diagnosis. The employers that terminated
people with HIV/AIDS were usually small buisness
owners.
Stigmatization increased with the number of
people that knew about the diagnosis. Some respondents had to change their place of residence
because of stigmatization but those who lived in
their own homes were not able to change their
place of residence. Some respondents spent up to
half of their household income on AIDS/HIV care.
They felt stigmatized by family, friends and colleagues at work.
Not employing PLWHA is a loss on the countrys
economy because loss of a job by a family member
affects their dependents and transcends beyond
the person infected with HIV/AIDS which in turn
can lead to some children dropping out of school
and may put them at risk of being lured into risky
behaviors thereby increasing their chance of becoming infected. Countries with high unemployment
will have a high incidence of crime which destabilizes the economy [14]. Ultimately, looking after the
whole person and not just drug provision is promoting a better economy for the country and sustaining the future of the children and the country.
Conclusion
The youngest respondent was 16 years old and the
oldest was 75. More than half of the respondents
were from Igbo ethnic tribe followed by Yorubas.

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Competing interests
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Authors' contributions
TTO conceived the study design, assisted in data
collection and analysis. TTO wrote the entire manuscript.
Acknowledgements
The author wishes to express her appreciation to
the staff and to the patients at the HIV/AIDS clinic
at the Lagos University Teaching Hospital and to
the eleven final year medical students that volunteered in the data collection. The author thanks the
management of Lagos University Teaching Hospital
and the College of Medicine, University of Lagos my
former employers.
I would also like to acknowledge Virginia Polytechnic Institute and State Universitys Open Access
Subvention Fund (OASF).
10
2015

ISSN: 1755-7682
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Vol. 8 No. 26
doi: 10.3823/1625
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